Why Hospitalists Should Heed Choosing Wisely Recommendations

By now, most hospitalists are at least familiar with the Choosing Wisely campaign, which has been widely published and embraced by numerous medical societies, including the Society of Hospital Medicine.1 This campaign was conceived in 2009 by the National Physicians Alliance, which developed simple lists for three primary care specialties—internal medicine, pediatrics, and family medicine—to help them become more effective in utilizing specific resources.

The effort was first published in the Archives of Internal Medicine in 2011 by the “Good Stewardship Working Group,” which outlined the five most overutilized types of care by the three groups, including items such as routinely ordering complete blood counts or electrocardiograms, prescribing brand name versus generic statin drugs, and prescribing antibiotics for pediatric pharyngitis. From this small list alone, they found incredible variability among primary care practices, with utilization of these services ranging from 1% to 56% and resulting in an estimated annual cost of $6.8 billion. Although this first pilot found simple reductions in utilization can have a powerful impact on cost, the group estimated that this overutilization in primary care is only a very small fraction of overutilization cost in the U.S. As such, they called upon other specialties outside of primary care to identify their own sets of targets to reduce unnecessary utilization of low-value services.

Many specialty groups heeded this call to action, which resulted in the Choosing Wisely campaign, launched in April 2012. In just two short years, this simple effort has expanded to published recommendations about resource use in more than 60 specialty societies.2 Like the original primary care list, most recommendations have focused on overutilization of diagnostic testing (imaging, cardiac testing, labs, pathology) and medication use. Later this year, the campaign will expand to include non-physician provider organizations, including the American Dental Association, the American Physical Therapy Association, and the American Academy of Nursing.

Later this year, the campaign will expand to include non-physician provider organizations, including the American Dental Association, the American Physical Therapy Association, and the American Academy of Nursing.

The Next Phase

The program has evolved from asking specialty groups to develop consensus and abide by their lists to targeting patients and their families so that they can understand and abide by those same lists. In fact, one of the major aims of the campaign is empowering patients to insist on care that is evidence based, necessary, not duplicative, and more beneficial than harmful. To do this, Consumer Reports has partnered up with the Choosing Wisely campaign to develop patient-friendly educational materials and with multiple consumer groups to help these materials reach their target audience. Major funding for the project has been provided by the American Board of Internal Medicine (ABIM) Foundation and the Robert Wood Johnson Foundation (RWJF). So far, they have awarded 21 projects.

These grants have been awarded to medical societies (see “SHM Choosing Wisely Case Study Competition,” p. 4), regional health organizations, and consumer advocate groups. Many of the tactics will include educational campaigns to teach practitioners about the content of the recommendations, programs aimed to enhance physician communication skills geared toward practicing physicians, other educational campaigns geared toward patients and families, and the establishment of a learning network to assist practices in quickly and effectively learning from one another how to implement the various recommendations.3

The three major assets of the Choosing Wisely campaign are:

It attacks a core issue within the medical industry: Healthcare costs are higher here than in any other industrialized nation in the world, without clear evidence of higher quality to justify that cost;

The lists are created by those who are responsible for most of the spending; and

The campaign is spending resources to get information to the patients and their families so that there will be bilateral exchange and acceptance of the recommendations.

Without widespread patient education, overutilization will likely continue; a recent survey sponsored by the Choosing Wisely campaign found about half of physicians admitted they would order a test they know is unnecessary if the patient is insistent.4

Variable Outcomes

While there are many reasons to celebrate the success of the campaign, there is some concern that the Choosing Wisely campaign may have unintended consequences. Although a major driver in the success of the program is the fact that the lists have been created and endorsed by physician societies, a sort of “self-governance,” with no influence or impact from payers, critics of the program note the variability that each list has on the actual practice or revenue of the physician groups enacting the lists.

For example, a recent New England Journal of Medicine (NEJM) essay notes that the list produced by the American Academy of Orthopedic Surgeons does not include procedures that are high volume and variably valuable (such as knee arthoplasty) but does include over-the-counter medication use and low-volume procedures (such as needle lavage for knee osteoarthritis).5 Some societies list specialty services that need to be curbed but neglect to mention their own.

And, although the campaign specifically states on its website that the “recommendations should not be used to establish coverage decisions or exclusions,” some are legitimately concerned that these Choosing Wisely lists might very well be used by payers and/or quality reporting bodies to determine payments. This is undeniably tempting: How can practitioners argue against public display and reimbursement schemes being tightly tethered to their performance on metrics that they themselves have deemed unnecessary? As the NEJM editorial summarizes, these efforts should be embraced as long as there is thoughtful discussion about inclusion criteria, exclusion criteria, and measurement beforehand.5

In Sum

Despite concerns, the impact of the Choosing Wisely campaign has been widespread and impressive. The full extent to which this will have an impact on utilization and healthcare cost remains to be seen, but this yeoman’s attempt to reduce waste by providers is long overdue. Whether the program will be used for unintended purposes, such as public reporting, financial penalties, or incentives for performance, is still unknown, but physician groups should be paying close attention to the lists that we can impact, and we should pledge to be good stewards of the finite healthcare resources available to our patients.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.